Chapter 22.  Childhood Disorders

Slide 1: Time to think

Slide 2:  Why is work with children and teens fun?

Slide 3: Why is work with children and teens challenging?

• What is "normal" behavior?
• Some problems are "normal" at some points and abnormal at others.
• Others are healthy -- even when they drive adults crazy!
• Child depression may or may not look like adult depression.
• Is this a "bad" child or a "sad" child?
• Problems with self-reports
• They are not good self-observers.
• They may only be able to identify two or three emotions.
• They are often less insightful about their inner experience -- & adults aren't all that good!!!

Slide 4: Major Depressive Episode

(1) Depressed mood most of the day
(2) Markedly diminished interest or pleasure
(3) Significant weight loss or gain when not dieting
(4) Insomnia or hypersomnia nearly every day
(5) Psychomotor agitation or retardation
(6) Fatigue or loss of energy nearly every day
(7) Feelings of worthlessness or excessive guilt
(8) Diminished ability to think or concentrate
(9) Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide
      attempt or a specific plan for committing suicide

Slide 5.

Slide 6. Attention-Deficit/Hyperactivity Disorder (APA, 1994)

A. Either (1) or (2):

(1) symptoms of inattention to a degree that is maladaptive and inconsistent with developmental level (6 +, 6 mo.+):

 a.  often fails to give close attention to details or makes careless mistakes in schoolwork, work,     or other activities;
 b.  often has difficulty sustaining attention in tasks or play activities;
 c.  often does not seem to listen when spoken to directly;
 d. often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions);
 e.  often has difficulty organizing tasks and activities;
 f.  often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework);
 g.  often loses things necessary for tasks or activities (e.g. toys, school assignments, pencils, books, or tools);
 h.  is often easily distracted by extraneous stimuli;
 i.  is often forgetful in daily activities:  OR

(2) symptoms of hyperactivity-impulsivity to a degree that is maladaptive and inconsistent with developmental level (6+, 6 mo. +):
hyperactivity;

 a.  often fidgets with hands or feet or squirms in seat;
 b.  often leaves seat in classroom or in other situations in which  remaining seated is expected;
 c.  often runs about or climbs excessively in situations in which it  is inappropriate (in adolescents or adults, may be limited to  subjective feelings of restlessness);
 d.  often has difficulty playing or engaging in leisure activities   quietly;
 e.  often "on the go" or often acts as if "driven by a motor";
 f.  often talks excessively:

impulsivity;

 g.  often blurts out answers before questions have been   completed;
 h.  often has difficulty awaiting turn;
 i.  often interrupts or intrudes on others (e.g., butts into   conversations & games)

B.  Some symptoms present before 7 y.o.
C. Impairment in 2+ settings is present
D.  causes significant impairment in social, academic, occupational functioning
E.  does not occur exclusively during course of Pervasive Developmental Disorder, Schizophrenia, or other Psychotic disorder and not better accounted for by other disorder.
p. 363

Slide 7. Gender and age differences in diagnosis with ADHD (Cohen, 1993)

Slide 8. Changes in positive behavior when on Ritalin or placebo (Pellham, 1993)

Slide 9. Changes in negative behavior when on Ritalin or placebo (Pellham, 1993)

Slide 10. Treatment of ADHD

• 80% (S), 50% (A) moderately improved
• Mild to moderate side effects
• High relapse rate

• About 40%  moderately improved
• Low to moderate relapse rate

• Somewhat more effective than either alone
• Lower relapse rate than medicine alone

Slide 11. Oppositional defiant disorder, cont. (APA, 1994)

A. A pattern of negativistic, hostile, & defiant behavior (4+, at least 6 mos.):

 1. often loses temper;
 2. often argues with adults;
 3. often actively defies or refuses to comply with   adults' requests/rules;
 4. often deliberately annoys people;
 5. often blames others for own mistakes/misbehavior;
 6. often touchy or easily annoyed by others;
 7. often angry/resentful; often spiteful or vindictive.

B. Causes significant impairment in social, academic, occupational functioning
C. Behaviors do not occur exclusively during course of Psychotic or Mood disorder.
D. If 18 years or older, does not meet criteria for Antisocial P.D.
p. 361

Slide 12. Gender and age differences in diagnosis with ODD (Cohen, 1993)

Slide 13. Mental retardation (Axis II) (APA, 1994)

A. Significantly subaverage intellectual functioning (IQ of 70 or less, or judgment of subaverage intellectual functioning for infants);
B.  concurrent deficits or impairments in present adaptive functioning (i.e. the person's effectiveness in meeting the standards expected for his or her age by his or her cultural group) (2+):  communication, self-care, home living, social/interpersonal skills, use of community resources, self-direction, functional academic skills, work, leisure, health, and safety;
C. onset is before age 18 years.   p. 330

Slide 14. Mental retardation (Axis II) APA, 1994

mild -- IQ of 50-55 to 70
moderate -- IQ of 35-40 to 50-55
severe -- IQ of 20-25 to 35-40
profound -- IQ below 20-25

Slide 15. Goals of treatment

Improve social and adaptive living skills
Increase independence in living

Slide 16. Reading disorder (APA, 1994)

A. Reading achievement, as measured by individually administered standardized tests of reading accuracy or comprehension, is substantially below that expected given the person's chronological age, measured intelligence, and age-appropriate education;
B. The disturbance in Criterion A significantly interferes with academic achievement or activities of daily living that require the composition of written texts (e.g. writing grammatically correct sentences and organized paragraphs);
C. If a sensory deficit is present, the difficulties in writing skills are in excess of those usually associated with it.

Slide 17. Mathematical disorder (APA, 1994)

A. Mathematical ability, as measured by individually administered standardized tests, is substantially below that expected given the person's chronological age, measured intelligence, and age-appropriate education.
B. The disturbance in Criterion A significantly interferes with academic achievement or activities of daily living that require the composition of written texts (e.g. writing grammatically correct sentences and organized paragraphs);
C. If a sensory deficit is present, the difficulties in writing skills are in excess of those usually associated with it.

Slide 18. Disorder of written expression (APA, 1994)

A. Writing skills, as measured by individually administered standardized tests (or functional assessments of writing skills), are substantially below those expected given the person's chronological age, measured intelligence, and age-appropriate education.
B. The disturbance in Criterion A significantly interferes with academic achievement or activities of daily living that require the composition of written texts (e.g. writing grammatically correct sentences and organized paragraphs);
C. If a sensory deficit is present, the difficulties in writing skills are in excess of those usually associated with it.

Slide 19: Time to think...

Slide 20: Conduct disorder (APA, 1994)

 aggression to people and animals:

 1. often bullies threatens/intimidates;
 2. often initiates physical fights;
 3. has used a weapon that can cause serious physical harm to  others;
 4. has been physically cruel to others;
 5. has been physically cruel to animals;
 6. has stolen while confronting a victim;
 7. has forced someone into sexual activity;

destruction of property:

 8.  has deliberately engaged in firesetting with the   intention of causing serious damage;
 9.  has deliberately destroyed others' property

deceitfulness or theft:

 10. has broken into house, building or car;
 11. often lies to obtain goods or favors or to avoid   obligations;
 12. has stolen items of nontrivial value without confronting a victim

serious violations of rules:

 13.  often stays out at night despite parental     prohibitions, beginning before 13 y.o.;
 14.  has run away from home overnight at least 2x    while living with parent or surrogate (or 1x if for lengthy period);
 15.  often truant, beginning before 13 years old

Slide 21. Gender and age differences in diagnosis with ODD (Cohen, 1993)

Slide 22: Problems may have multiple causes

• Biological problem
• Problems at home
• Poor teacher/student match
• Frustration with learning process
• Poor peer or dating relationships
• Confusion about sexual orientation -- up to 50% of suicides are attributed to this
• Poor social skills
• How do you choose among these?
• More than one problem may contribute.

Slide 23: Predictors of school violence

• Witnessing violence at home, in the community or in the media
• The need for attention or respect
• Early childhood abuse or neglect
• Feelings of low self-worth
• Peer pressure
• Easy access to weapons

• Coming from a family with a history of criminal violence
• Being abused
• Belonging to a gang
• Abusing drugs or alcohol

• Using a weapon
• Having been arrested
• Having a neurological problem that impairs thinking or feeling
• Having had problems at school

Slide 24: Limits to prediction

• Violence is a low frequency behavior.  We tend to overpredict its presence.
• While there are factors that increase or decrease risk of suicide or violence, we can not predict violence with a large degree of certainty.
• Predictors may be overlooked when we focus on the likeable aspects of a child.
• On the other hand, focusing on the likeable parts of a child can help them change.

Slide 25: Risk factors at Columbine

• Were members of the Trenchcoat mafia
• Felt alienated and disrespected by peers
• Had been arrested for breaking into a van and stealing electronics
• Were on probation
• Described how to make bombs on web page
• Had threatened another student with a gun
• Were enamored of the Nazi culture

Slide 26: On the other hand...

• Came from “good” families
• Were excellent students and bright

"Dylan is a bright young man who has a great deal of potential.  He is intelligent enough to make any dream a reality but he needs to understand hard work is part of it."

"No one can predict lethality.  If every murderer looked like Charles Manson, it would be easier.  But if they look like Ted Bundy, you're in trouble.”
                                                                                                        Supervisor of probation officer
                                                                                                        Who evaluated Harris and Klebold

Slide 27: Moral of the story

• While we cannot predict violence accurately 100% of the time, there are factors that put teens at risk.
• We can do things that decrease the probability of violence.
• The nature of these interventions are such that almost every child can profit.

Slide 28: What can we do?

• Reduce scapegoating and prejudice.
• Help all students develop a healthy and realistic self-esteem.
• Create primary prevention programs for children at-risk of being abused and intervene early.
• Find mentors for all students.
• Recognize students’ strengths as well as their weaknesses.
• Teach anger management techniques.
• Make weapons unavailable.
• Identify students with mental health issues and get them help.
• Take threats seriously.
• Recognize risk factors and get at-risk students help.
• Remember our tendency to excuse “good” or quiet kids.

Slide 29: Time to think...

Slide 30: How do we teach body image?

Slide 31: Culture’s role in eating disorders

• Not found in cultures where access to food is an issue, only where it is plentiful.
• In US:
• 90-95% women, often White, middle-class, living in a competitive environment
• low incidence among Blacks, Hispanics, Native Americans
• Typical age of onset 16-19
• 6-8% of college women are bulimic
• Increased risk in recent years, increased risk with younger girls
• "Typical" anorexic family: Successful, driven, eager to maintain harmony, concerned about appearances

Slide 32: Messages about weight in the media

Slide 33: Titian's Woman with a mirror (c.1513-1515)

Slide 34: Manet's The surprised nymph (1861)

Slide 35: Renoir's Bathers (1918)

Slide 36: Gucci advertisement

Slide 37: Bulimia nervosa (APA, 1994)

(1) eating in a discrete period of time (e.g. within any 2-hour   period), an amount of food that is definitely larger than most  people would eat during a similar period of time and under similar  circumstances and
(2) a sense of lack of control over eating during the episode (e.g.  a feeling that one cannot stop eating or control what or how  much one is eating);

Slide 38: What is a binge?

• Feeling of being out of control while eating
• More "junk food" than typical (Rosen et al., 1986)
• How big?
• 27% > 2000 cal, 33%< 600 cal
• Mn = 1459.
• "Nonbinge" episode = 321  cal.
• How much is this?
• 12 oz sweetened ice tea (131 cal) & Hershey's with almonds (230 cal) = 361cal
• 18 chocolate chip cookies (810 cal) & 4 oz of corn chips (612 cal) = 1422 cal
• 4 c popcorn with 2T butter (424) & 4 slices Pizza Hut thin crust pizza (820 cal) & Whopper with cheese (730) = 1974

Slide 39: And purging?

• Attempts to compensate for binge and weight gain
• Laxatives: 15%
• Purging: 70-90%
• Diuretics (at least occasional): 33%
• Fasting
• Enemas: 7%
• Chew & spit to avoid swallowing: 65%
• Exercise
• Purgers show more pathology (more binging, higher prevalence of depression and panic across lifespan, higher scores on  measures of pathological eating attitudes & behavior)

Slide 40: Medical complications

• Most are within 10% of normal weight
• Salivary gland enlargement, giving face a "chubby" look
• Decay of dental enamel
• Menstrual problems
• Electrolyte imbalance, causing serious complications including heart attacks and death
• Callouses on fingers or back of hands from causing vomiting

Slide 42: And also...

Slide 43: Anorexia nervosa (APA, 1994)

Slide 44: Anorexia nervosa, cont.

• Loss of weight, but low weight may be due to other reasons
• Refusal to maintain greater weight
• Fear of obesity & attempts to lose weight
• Often good at saying the things they believe their doctors want them to say.
• Often involuntary clients
• Two types:
• restrictor
• binge/purge -- Small amounts of food in "binge"
• More stealing, drug and alcohol use, self-mutilation, variable moods

Slide 45: Important therapeutic issues

• Control
• Poor discussion of feelings and problems in family
• Overconcern with maintaining appearances
• Difficulty individuating from family

Slide 46: Medical complications

• Amenorrhea
• Brittle hair or nails, dry skin
• Intolerance of cold, decreased body temperature
• Low blood pressure
• Downy hair on limbs & side of face
• Heart arrhythmias
• Slowed bone growth
• Anemia
• Electrolyte imbalance, causing serious complications including heart attacks and death

Slide 47: Percentage change in bingeing (Agras et al, 1994)

Slide 48: Percentage change in purging (Agras et al, 1994)

Slide 49: Treatments

• Cognitive-behavioral therapy
• What are triggers for binges and purges?
• What are cognitions around stress and eating?
• Good response, low to moderate relapse
• Antidepressants (SSRIs)
• Useful for people with bulimia, but high relapse rates when used alone
• Family therapy
• Good response. Moderate relapse rates

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URL= http://psy1.clarion.edu/jms/Abn1abnormal.html

Last modified October 24, 2001.